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SAN JOA.&COUNTY ENVIRONMENTAL HEALT106ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station ::L 37/ 7 .S 40 LIS"44 <br /> OWNER/OPERATOR <br /> Chevron USA CHECKIfOl NGADDREss® <br /> FAciuTYNAME Chevron <br /> SITE ADDRESS 4344 € Waterloo Rd Stockton 95215 <br /> n umber .-WnKAIO SIrW Name city Zip Cod* <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number tnel s <br /> CITY STATE Zip <br /> PHONE#f EXT' APN I LAND USE APPLICATION II <br /> ( ) 1®1- O2( -S6 <br /> PHONE#2 EXT. 80S DISTRICT LOCATON CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK IfBILLING ADDRESS <br /> � <br /> BUSINESS NAME Service Station System, Inc. PHONE# EXT, <br /> 408 213-6038 <br /> HoME or MAILING ADDRESS 680 Quinn Avenue FAx# <br /> (408 ) 971-0135 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of Same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that l have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ILL" ii.Lk-V ~/�-E�i �t1��1 DATE: 9/15/09 <br /> PROPERTY/BUSINESS OwNERM OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT a Compliance Officer <br /> IfAPPLICANr is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative, u,S7- 4F—T-�8� t-F- <br /> TYPE OFSERWE REQUESTED: <br /> F--TYPEOFSERWEREQUESTED: UST inspection T <br /> COMMENTS: �ECEN <br /> SEP � 6 20 9 <br /> SAN 3OApU1N Co NN <br /> HF N {0EPAR ENT <br /> ACCEPTED BY: {�C_t i EMPLOYEE M ® 3 u DATE: <br /> ASSIGNED TO: w D ^/ EMPLOYEE#: (��8' DATE; <br /> Date Service Completed (H already completed): SERVICE CODE: G}� P f E: 2-3 0S <br /> Fee Amount: -4 3 S d a Amount Paid Lt's _ Payment Date 4k l(� <br /> Payment Type �� Invoice# Check# 2 Recelved By: <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �; C 0 <br />